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MIR-2007-2AB, February 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Skilled Nursing Facility (SNF) Consolidated Billing (CB) Common Working File (CWF) Edit Bypass Instructions for Hospital Emergency Room Services Spanning Multiple Service Dates
| Note: This article was revised on January 12, 2007, to reflect that CR5389 was revised. The CR release date and transmittal number (see below) are changed and the Web address for accessing CR5389 has been revised. All other information remains the same. |
Provider Types Affected
Providers who submit hospital emergency room claims paid under the OPPS to Medicare fiscal intermediaries (FI) or Part A/B Medicare Administrative Contractors (A/B MAC).
Provider Action Needed
Impact to You
The common working file (CWF), a portion of Medicare’s claims processing system, will reject hospital claims (including those from critical access hospitals (CAH)) for emergency services that you provide to beneficiaries who are in Part A skilled nursing facility (SNF) stays, if these services span more than one day; unless the hospital identifies them by appending modifier ET (Emergency Services) to those line items.
What You Need to Know
Emergency room services that hospitals (including critical access hospitals [CAH]) provide to beneficiaries in skilled Part A skilled nursing facility (SNF) stays are excluded from SNF consolidated billing (CB). When these emergency room services span more than one service date, the CWF rejects the services that are provided on the subsequent service dates, because the line item date of service (LIDOS) for these services does not match the LIDOS reported under 045X revenue code.
What You Need to Do
Make sure that your billing staffs identify claims for emergency services that 1) You provide to beneficiaries in skilled Part A skilled nursing facility (SNF) stays, and 2) That span more than one day; by appending modifier ET (Emergency Services) to line item date of service on outpatient bill types 13X and 85X when revenue code 045x (Emergency Room) is present on the claim.
Background
CR 5389, from which this article is taken, clarifies instructions in CR 4252 (Transmittal 881) entitled “Outpatient Prospective Payment System Emergency Room Services Exceeding 24 Hours” that was released March 3, 2006. CR 4252 provided that hospital OPPS claims submitted for emergency room services should be identified with revenue code 045X; using as the service date, the date that the emergency service was provided. It further provided that if the patient were in the emergency room after midnight, only the one service date should be used.
This guidance, however, requires clarification when related to emergency room (ER) services that a hospital provides to beneficiaries in skilled Part A skilled nursing facility (SNF) stays. Specifically, ER services (and all services related to that ER encounter) that hospitals (including CAHs) provide to beneficiaries in skilled Part A SNF stays are excluded from SNF consolidated billing (CB).
Further, current common working file (CWF) SNF CB edits contain bypasses that allow ER related services with LIDOS that match the reported LIDOS on the 045X revenue code to bypass SNF CB edits. However, when services related to the ER encounter (for beneficiaries in Type A SNF stays) span more than one service date, the encounter-related services that are performed on subsequent service dates are currently being rejected by the CWF because the LIDOS for these services does not match the LIDOS reported under 045X ER revenue code.
Therefore, in order to bypass the ER encounter-related services that hospitals provide on a subsequent service date to beneficiaries in Type A SNF stays, CR 5389 instructs hospitals to identify those services by appending the modifier ET (Emergency Services) to line item date of service on their outpatient bill types 13X and 85X when revenue code 045X (Emergency Room) is present on the claim. The reporting of the ET modifier will alert CWF that these are related ER services performed on subsequent dates so that it will bypass the SNF CB edits.
Additional Information
You can find the official instruction, CR5389, issued to your FI or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1151CP.pdf  on the CMS Web site. Attached to that CR, you fill find updated Medicare Claims Processing Manual (Publication 100-04), Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS), Section 180.6 (Emergency Room Services That Span Multiple Service Dates), and Chapter 6 (SNF Inpatient Part A Billing), Section 20.1.2.2 (Emergency Services).
If you have any questions, please contact your FI or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  on the CMS site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5389 Revised
Pub. 100-4, Transmittal# R1151CP, CR# 5389
Related CR Release Date: January 11, 2007
Effective Date: October 1, 2005
Implementation Date: April 2, 2007
Flu Shot Reminder
As a respected source of health care information, patients trust their doctors’ recommendations. If you have Medicare patients who haven’t yet received their flu shot, help protect them by recommending an annual influenza and a one time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. – And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.
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